Psychiatric medications, science, marketing, psychiatry in general, and occasionally clinical psychology. Questioning the role of key opinion leaders and the use of "science" to promote commercial ends rather than the needs of people with mental health concerns.

Thursday, September 25, 2008

This post details the duplicate publication of data on the antidepressant duloxetine (Cymbalta). Marketing and "science" collide to produce hideous offspring: an experimercial that pimps Lilly's bogus "Depression Hurts" marketing for Cymbalta using the exact same (weak) data twice. Data were published in the Journal of Clinical Psychiatry (JCP), and then the same data were published a second time in the Journal of Psychiatric Research (JPR), a blatant violation of JPR policy. Oh, and Alan Schatzberg, president-elect for the American Psychiatric Association is involved in the story.

The study: Lilly conducted a rather uninteresting study of Cymbalta, in which patients who had not shown a treatment response to an SSRI were then assigned to either a) Direct switch: Switch to Cymbalta and immediately discontinue the SSRI medication or b) Start-Taper-Switch: taper the SSRI over a 2 week period while also starting Cymbalta. Note that there was not a control group of any sort, an issue that the authors dance around (i.e., essentially ignore) in the papers based on this study's data.

Publication #1 -- Journal of Clinical Psychiatry: Data from this study were published in the January 2008 issue of the Journal of Clinical Psychiatry. The findings were that, in essence, there were no notable differences between patients who were directly switched to Cymbalta as opposed to those who did the start-taper-switch method. But what do the authors conclude?

Despite the lack of control group, the authors get the message out that not only was depression improved, so were "painful physical symptoms." As anyone who has a television has probably noticed, Lilly has been pushing hard for quite some time to convince patients and physicians that Cymbalta will relieve depression andpainin depressed patients. So if the marketing points can be pushed in one journal, why not pimp the same idea using the same data in another journal?

Publication #2 -- Journal of Psychiatric Research: Data from the same study were published online (to appear in print soon) in the Journal of Psychiatric Research (JPR). And I mean the exact same data appear again in this paper. This is a huge scientific no-no. Findings are supposed to be published once, not over and over again. Journals are struggling to find space for new and interesting findings, so there is no need to waste space on duplicate data. In fact, to quote from JPR's website

Submission of a paper to the Journal of Psychiatric Research is understood to imply that it is an original paper which has not previously been published, and is not being considered for publication elsewhere. Prior publication in abstract form should be indicated. Furthermore, authors should upload copies of any related manuscript that has been recently published, is in press or under consideration elsewhere. The following circumstances indicate that a paper is related to the manuscript submitted to the Journal: a) any overlap in the results presented; b) any overlap in the subjects, patients or materials the results are based on.

So it's pretty clear -- don't submit data that has already been published. Here is a figure from the Journal of Clinical Psychiatry (JCP) article mentioned above:

And here is the same data, in a figure in JPR:

But wait -- that's just the beginning. How about the data tables... From JCP:

And the right-side half of this table in JCP:

And the exact same data appearing in JPR:

To be fair to these "researchers" in JPR, they reported data from subscales of two measures not reported in JCP. But the vast majority of the data is just reprinted from the article in JCP. Which is completely trouncing journal policy and, more importantly, conveying Lilly's marketing messages to the audiences of two different journals. Unfortunately, they apparently did not consider that some people might actually read both journals and notice that essentially the same article had appeared twice. Or, Lilly considered this prospect and said, "Who cares." I'll leave it to my readers to decide if they care.

Authors: The JCP paper was authored by David Perahia, Deborah Quail, Derisala Desaiah, Emmanuele Corruble, and Maurizio Fava. The JPR paper was "authored" by Perahia, Quail, Desaiah, Angel Montejo, and Alan Schaztberg. So to re-publish the same data, it was out with Corruble and Fava -- in with Montejo and Schatzberg. Why Schatzberg? We're almost there...

JPR describes the contributions of each author. For these two authors (Schatzberg and Montejo) who were not credited in the JCP paper, they were both described as "involved in data review and interpretation, including the development of this manuscript." How could they have been involved with data review and interpretation -- the vast majority of the data were already analyzed, interpreted and written up by other researchers in the JCP paper? Did they write the paper? Apparently not, since the JPR article mentioned that "Dr. Desaiah worked with Dr. Perahia to draft the manuscript..." So Montejo and Schatzberg could not conceivably have played any significant role in data analysis, interpretation, or writing the paper. It seems that if Desaiah and Perahia "drafted" the manuscript, then the most Montejo and Schatzberg could have done is to maybe review the paper.

So why is Schatzberg on the paper? Well, it just so happens, I'm sure by sheer coincidence, that Schatzberg is the co-editor in chief of JPR. So he'd be in a good position to help a paper that essentially republishes data from JCP with only minor additions make it into publication against his own journal's policies.

Nice work, Schatzberg. That's pimpin' it hard. That, my friend, is worthy of nomination for a coveted Golden Goblet Award. Congratulations. It is not the first time Schatzberg's "scientific" behavior has been noted. He has been stumping (in the face of much contradictory data) in favor of his pet drug RU-486/Corlux in the treatment of psychotic depression for some time. Between the bad science surrounding Corlux and Schaztberg's myriad conflicts of interest, much has been written (1, 2, 3, 4, 5) -- add another chapter to the chronicles of the storied American Psychiatric Association Leader. This reminds me of an earlier incident involving Charles Nemeroff.

Discussion: As I've noted previously, the discussion section of a journal article often contains key marketing points, science being relegated to secondary status at best. The JPR article provides a few good examples of Cymbalta's talking points:

The current paper focuses on pain-related outcomes, demonstrating that a switch of SSRI non- or partial-responders to duloxetine was associated with a significant improvement in all pain measures including six VAS pain scales, the SQ-SS and its pain subscale, and the SF-36 bodily pain domain.

Switch of SSRI non- and partial-responders to duloxetine resulted in mean improvements on all pain measures regardless of the switch method used.

Duloxetine, an SNRI, has previously been shown to be effective in the treatment of PPS associated with depression, and it is also effective in the treatment of chronic pain such as diabetic peripheral neuropathic pain (DPNP) for which it is approved in the US, Europe and elsewhere, so duloxetine’s effects on pain in our sample of SSRI non- or partial-responders was not unexpected.

Patients with MDD present with a broad range of symptoms including those related to alteration of mood and PPS, all of which may contribute to global functional impairment. Effective treatment of both mood symptoms and PPS associated with depression may therefore optimize the chances of functional improvement. Recent findings that residual PPS in depressed patients may be associated with impaired quality of life (Wise et al., 2005, 2007), decreased productivity and lower rates of help seeking (Demyttenaere et al., 2006) and a lower likelihood of attaining remission (Fava et al., 2004), further demonstrate the importance of effective treatment of PPS in patients with MDD, so duloxetine’s effects on PPS are reassuring.

Improvements in pain are consistent with previously reported studies demonstrating duloxetine’s efficacy for pain, either as part of depression, or as part of a chronic pain condition such as DPNP.

7. Discussion: The results of your study should be placed in the appropriate context of knowledge, with discussion of its limitations and implications for future work.

So maybe if there was research that questions Lilly's talking points about Cymbalta relieving pain in depression, such research should be discussed. Well, it just so happens that there is research, which analyzed Lilly's own clinical trials and found that Cymbalta was no better than a placebo or Paxil in treating pain in depression. This meta-analysis of Cymbalta trials was published in January 2008, yet the JPR article, which was originally received by JPR on March 26, 2008 did not mention the negative data. Hmmm, that doesn't exactly sound like placing the findings "in the appropriate context of knowledge," does it? All this talk about Cymbalta's fantastic analgesic effects despite Lilly's own data showing that Cymbalta is at best close to useless in treating pain among depressed patients. Another study that claimed to show Cymbalta was a helluva painkiller was also smacked in a letter to the editor a few months ago -- and the authors of the Lilly-sponsored trial conceded defeat by refusing to reply to the critiques of their study.

Better Than "Weak" SSRIs (Not Really): In the JPR study, it was mentioned that the evidence for SSRIs in treating pain is "weak." No disagreement on my end. But see, once SSRI patients switched to Cymbalta, their pain magically went away because Cymbalta, unlike SSRIs, relieves pain. Never mind the lack of control group, which was allotted a grand total of 15 words in the discussion as a potential limitation of the study. The authors also failed to note that prior research showed that Cymbalta was no better than Paxil in treating pain in depressed patients. And Perahia, the lead author of the JCP and JPR "studies" is certainly aware of the research showing that Cymbalta works no better than a "weak" SSRI, since he was the lead author on one such study! So he is quite aware that Cymbalta has never been shown superior to Paxil in treating pain, yet he accurately describes research indicating that SSRIs are "weak" pain treatments, but then neglects to mention that Cymbalta failed to demonstrate superiority to Paxil in treating pain in depression. This is called lying by omission.

I may pass along my concerns to the Journal of Psychiatric Research. My prior experiences in passing along such concerns to journals via my blog identity is that they either a) ignore my concerns entirely or b) instruct me to write a letter to the editor which would be considered for publication, with the stipulation that I use my real identity. Sorry, but a published letter to the editor is not worth blowing my cover.

Call for Action: Rather than my running into point b. from the last paragraph, how about one or more scientifically inclined readers submit your concerns to the journal, under the following condition: Make sure you read the original papers first to judge if my concerns are valid. Then, if you feel similarly, why not send a letter to the editor? This is bad science which does nothing to advance patient care -- it seeks only to advance sales of Cymbalta by pimping it as a painkiller in depression while ignoring all contradictory data. So let's try a little research of our own -- see if JPR is willing to address these issues or if they will be swept under the rug.

15 comments:

Excellent piece of investigative journalism. I don't think many people, who would have read both articles, would have picked up on the same data being used.

As for Schatzberg, I wonder, should a letter be sent to his journal, if anything would actually come of it. However, because of the complacency of the psychiatric community, I would imagine nothing would come of it.

Thanks for the plug of my site a few days ago. That was much appreciated. Keep up the good work.

I have responded to your challenge and contacted the journal. Of course, there is no point in approaching the compromised editor, Dr. Schatzberg, so I went directly to the journal's publisher. Others can do the same by writing to 'v.pradalopez@elsevier.com' and 'L.Colson@elsevier.com'

Readers also should make the American Psychiatric Association aware of this breaking controversy. Is this the ethical behavior the APA wishes its President-elect to be modeling for the field at large?

You may want to let Stanford, the employer of Dr. Schatzberg, know about this too. It seems that he has been in a bit of trouble over his undisclosed financial ties to the drug industry. Here's another link to a story about him.

Now, why would Schatzberg behave like this -- accept what looks like honorary authorship on a Lilly publication and pimp for Lilly by giving them product placement, while violating his own journal's policy?

Could it possibly have anything to do with the fact that Lilly threw Dr. Schatzberg's moribund company a lifeline with a research contract?

This is a fine example of academic-industrial cronyism, if you ask me.

In March of 2006, Lilly did press releases illustrating the amazing qualities of Cymbalta for anxiety, as well as pain and cognition issues from anxiety, claiming there was enormous relief of the patients in the study which was the focus of the press releases.

Several days afterwards, Lilly presented twice the same study illustrating the same benefits that were in the press releases at a national anxiety conference.

Yet it was not until May that Lilly subnitted a NDA to the FDA for the anxiety indication, which means both the press releases and meeting presentations were by definition both off label promotion and misbranding of Cymbalta.

That is all you do in this blog. You are so blinded by bias and hate, you never see positive effects from medication.

You have almost no one who rebuts your lying by omission blog. You have a bunch of disgruntled mental patients and loser, hasbeen clinicians. No one here is pointing out the mass of facts you are omitting.

Most of the objection, as on other hate websites is to prescribing brand medications to dark skinned people on Medicaid. Not just lying by omission but racism, just like that Independence Blue Cross running dog racist, Grassley.

Pharmalot banned me. It seems to permit commenting mostly by disgruntled mental patients who believe falsely that medications do not help. That is the way of the left, censorship of facts, personal attacks.

I point out a hypocrisy of this blogger, you make personal remarks. I work for no PR firm. I work for myself as a patient seeing companies keeping people alive attacked and attempts to defund them by left wing ideologues, lawyers, and racist health insurance companies with $trils in reserves. They accumulated these reserves by defunding hospitals and laying off thousands of health workers. Now, they are coming after brand named medications. And the hypocrite here is falling for their masking ideology. He is either young and healthy or an old, naive, self-defeating moron.

If you are over 40, an organ will fail every few years from here. I will cast the same curse on you that I did on Ed Silverman. You will remember me when your doctor says there is nothing more that can be done for your condition. That missing drug not developed will have been the fault of the hypocrite writing this hate speech blog and the scores of other left wing ideologues.

If people here cared about patients, they would stop missing the real causes of slow progress. The term of the patent for drugs should drop to five years. In exchange, close the FDA. Replace it with internet publication of data. Let doctors and patients decided for themselves, and provide daily feedback.

Supremacy Claus, pills like these don't keep people alive. At best they provide hope for patients who sadly have been misinformed and manipulated into believing that they have a medical illness (e.g. depression) that they cannot do anything about. More often they are powerful drugs designed to cross the blood-brain barrier where they cause a wonderful distraction for patients, such as impotence, weight-gain, somnolence (drug company lingo for sleepy), and agitation (again, fancy lingo to make things look "scientific").

If these drugs are so effective and helpful, why send young attractive pharma reps to educated, knowledgeable doctors around town, take them to lunch, buy them gifts, and in the process increase the overall costs associated with these drugs? Why not just let the research speak for itself? In this case, it clearly is saying something important about cymbalta.

If we care about patients, we should be increasing access to a variety of effective treatments. The primary of which should be how to live better in today's society/culture. Call it life-skills, cognitive therapy, whatever...People are unhappy because they live unhappy lives. We live in a culture that encourages us to avoid responsibility for our personal ills and make the changes necessary to improve our well-being.

Pharma sees a need and fills it. Just like diet pills, sleeping pills, botox injections, smoking cessation pills/patches/gums/inhalers, and countless other medications for glutenous conditions associated with living in America in 2008.

The difference is that Pharma has the money to sell the idea that you have a medical disease and need a medical treatment. There's no competition treatment with enough money to sell us on the alternatives. There is no corporation who can make billions selling:"Big Therapy for Responsible Living""Big Physical Exercise""Organization To Promote Getting Out of Your Abusive Relationship With Your Cheating Spouse" "Corporation To Aid In Tolerating The Full Range of Human Emotion"

How many people taking antidepressants have a disease versus one of these problems of living? In today's healthcare environment, it's: tell me your symptoms and I'll write you a prescription for the treatment/cure.

Sure, as you said, organs will fail, diseases will develop, illness will occur. But let's not mingle physical medicine with mental health. The two are most definitely separate. Medical illness exists in the living body and it's eventual corpse, whereas mental "illness", such as depression, are things you cannot detect in a corpse.

These statements are NOT aimed at minimizing the potential emotional suffering one can experience. But to market cymbalta and similar drugs with package inserts stating "Although the way Cymbalta works in people is not fully known..." is just ridiculous, exploitative, and unethical.

Moreover, all research done on a particular drug should be available to the public, not just the choice studies submitted for publication.

Presently, for the treatment of depression and other what some claim are other types of mental disorders that are at times questionable, selective serotonin reuptake inhibitors (SSRIs) are the drugs of choice by most prescribers today. Such meds, meds that affect the mind are called psychotropic medications. SSRIs also include a few meds in this class with the addition of a norepinephrine uptake inhibitor added to the SSRI, and these are referred to SNRI medications, which combined with SSRIs, are the number 1 top therapeutic class of prescriptions presently. While there are several available SSRIs presently, two SNRIs available are Cymbalta and Effexor. Some consider these classes of meds the next generation mood enhancers- after the benzodiazepine hype decades ago. Furthermore, regarding SNRIs, adding the additional agent of norepinepherine is presumed to increase the effectiveness of SSRIs by some.Some Definitions: Serotonin is a neurotransmitter thought to be associated with mood. The hypothesis was first suggested in the mid 1960s that this neurotransmitter may play a role in moods and emotions in humans. Yet to this day, the serotonin correlation with such behavioral and mental conditions is only theoretical. In fact, the psychiatrist’s bible, which is known as the DSM, states that the definite etiology of depression remains a mystery and remains unknown with complete certainty. So a chemical imbalance in the brain is not proven to be the cause of mood disorders, it is only suspected as a result of limited scientific evidence. In fact, diagnosing mental diseases such as depression is based on subjective assessment only, as interpreted by the prescriber, so one could question the accuracy of such diagnoses.Norepinepherine is a stress hormone, which many believe help those who have such mood disorders as depression. Basically, with the theory that by adding this hormone, the SSRI will be more efficacious for a patient prescribed such a med, as suggested earlier.And depression may be combined with related mood disorders that may exist with certain patients which increases the potential devastation of these concominant disease states. An accurate diagnosis of these mental conditions lack complete accuracy, as they can only be defined conceptually, so the diagnosis or impression concluded by the patient’s doctor is dependent on subjective criteria, such as questionnaires and patient observation. A social patient history is uncertain and tricky as well, some have said. There is no objective diagnostic testing for depression to validate as to whether or not the disease is present. Yet the diagnosis of depression in patients has increased quite a bit over the past few decades. Yet, one may ask, actually how many people are really depressed? What is believed is that if one is disabled or impaired from a mental paradigm if they are experiencing a major depressive disorder, and it is then that treatment is necessary and appropriate or reasonable with medicinal therapy, which at times is combined with behavioral or cognitive therapy as well. It has been reported that around 10 percent of the U.S. population will at some point be affected by a major depressive disorder. Due to such factors as depression being discussed recently in the media and medical literature, that may not be completely accurate or thorough, depression and the treatment and diagnosis of this disorder has increased remarkably in a short period of time in the United States. This depression issue is further encouraged by those pharmaceutical companies that market medications for major depressive disorders. So more people seek treatment now for what they believe is a major depressive disorder they are experiencing, when in fact it may be intense sadness, perhaps, due to a loss of some sort in their lives. There is a difference, and health care providers should have the appropriate tools and knowledge to discriminate between the two states of mental conditions. Sadness is not a medical problem. Symptoms associated with an unfavorable mental state need to be excessive and chronic to be considered to have in fact the medical problem of a major depressive disorder, as stated by others.In Time magazine’s June 16th 2008 cover story, it was reported that the military personnel in the Iraq war are pounding down SSRIs often. Every time there is a new war, there is a new drug, it seems. Yet the story may illustrate the frequent usage of these types of medications in a variety of different areas for different reasons. Some reasons may be valid and appropriate, yet others perhaps may not be reasonable for such medicinal therapy.In regards to those pharmaceutical companies who make and market such psychotropic drugs, what is known is that the psychiatry specialty is the one specialty most paid to by certain pharmaceutical companies for ultimately and eventual support of their psychotropic meds that they currently promote to these doctors, as this aspect of the pharmaceutical industry clearly desires market growth of these psychoactive medications. Front groups to expand the market for these types of drugs have been known to occur as well, which have on occasion been developed if not supported by such companies. Regardless, SSRIs and SRNIs are the preferred treatment methods if depression or other mood disorders that may be suspected by a health care provider. Yet these meds discussed clearly are not the only treatments, medicinally or otherwise, for depression and other related and suspected disease states. Patients should be aware of this fact as well as caregivers.Over 30 million scripts of these types of meds that enhance serotonin saturation in the brain are written annually, and the franchise is around 20 billion dollars a year now, along with some of the meds costing over 3 dollars per tablet, it has been reported. There are about ten different SSRI/SRNI meds available, many of which are now generic, yet essentially, they appear to be similar in regards to their efficacy and adverse events. The newest one, a SNRI called Pristiq, was approved in 2008, and is believed to be launched as a treatment for menopause. The first one of these SSRI meds was Prozac, which was available in 1988, and the drug was greatly praised for its ability to transform the lives of those who consumed this medication in the years that followed. Some termed Prozac, ‘the happy pill’. In addition, as the years went by and more drugs in this class became available, Prozac was the one of preference for many doctors for children. A favorable book was published specifically regarding this medication soon after it became so popular with others.Furthermore, these meds have received upon request of their marketers additional indications besides depression for some really questionable conditions, such as social phobia and premenstrual syndrome. With the latter, I find it hard to believe that a natural female experience can be considered a treatable disease. Social phobia is a personality trait, in my opinion, which has been called shyness or perhaps a term coined by Dr. Carl Jung, which is introversion, so this probably should not be labeled a treatable disease as well. There are other indications for certain behavioral manifestations as well with the different SSRIs or SRNIs. So the market continues to grow with these meds. Yet, it is believed that these meds are effective in only about half of those who take them, so they are not going to be beneficial for those suspected of having certain medical illnesses treated by such meds. The makers of such meds seemed to have created such conditions besides depression for additional utilization of these types of medications, which is a process known as disease mongering. Drug companies that make these medications are active and have been active in forming mutual relationships with related disease- specific support groups, such as providing financial support for screenings for the indicated conditions of their meds- which includes the screening of children and adolescents in particular, I understand, as mentioned earlier with their relationship with these front groups. As a layperson, I consider such activities dangerous and inappropriate for several reasons. Danger and concerns by others with these particular psychotropics primarily involves the adverse effects associated with these types of meds, which include suicidal thoughts and actions, violence, including acts of homicide, and aggression, among others, and the makers of such drugs are suspected to have known about these effects and did not share them with the public in a timely and critical manner. While most SSRIs and SNRIs are approved for use in adults only, prescribing these meds to children and adolescents has drawn the most attention and debate with others, such as those in the medical profession as well as citizen watchdog groups. The reasons for this attention are due to the potential off-label use of these meds in this population, yet what may be most shocking is the fact that some of the makers of these meds did not release clinical study information about the risks of suicide as well as the other adverse events related to such populations, including the decreased efficacy of SSRIs in general, which is believed to be less than 10 percent more effective than a placebo. Paxil caught the attention of the government regarding this issue of data suppression some time ago, this hiding such important information- Elliot Spitzer specifically was the catalyst for this awareness, as I recall. Furthermore, that drug is in the spotlight once again years later. Some believe the drug maker knew about possible risk to the youth as early as 1991. And there are very serious questions about the use of SSRIs in children and adolescents regarding the possible damaging effects of these meds on them. For example, do the SSRIs correct or create brain states considered not within normal limits, which in effect could cause harm rather than benefit? Are adolescents really depressed, or just experiencing what was once considered normal teenage angst? Do SSRIs have an effect on the brain development and their identity of such young people? Do adolescents in particular become dangerous or bizarre due to SSRIs interfering with the myelination occurring within their still developing brains? No one seems to know the correct answer to such questions, yet the danger associated with the use of SSRIs does in fact exist. It is observed in some who take such meds, but not all who take these meds. Yet health care providers possibly should be much more aware of these possibilities, possibly, along with the black box warning now on SSRI prescribing information for the youth that has existed since 1994. Finally, if SSRIs or SNRIs are discontinued by a patient without medical supervision, withdrawals are believed to be quite brutal, and may be a catalyst for suicide in itself, as not only are these meds habit forming, but discontinuing these meds abruptly, I understand, leaves the brain in a state of neurochemical instability, as the neurons are recalibrating upon discontinuation of the SSRI or SNRI that altered the brain of the consumer of this type of med. This occurs to some degree with any psychotropic med, yet the withdrawals can reach a state of danger for the victim in some classes of meds such as SSRIs and SNRIs, it is believed.SSRIs and SRNIs have been claimed by doctors and patients to be extremely beneficial for the patient’s well -being regarding the patient’s mental issues where these types of meds are used, yet the risk factors associated with this class of medications may outweigh any perceived benefit for the patient taking such a drug. Before these medications mentioned were developed, doctors praised trycyclics, another class of anti-depressants, in a similar manner some time ago. Considering the lack of efficacy that has been demonstrated objectively with these newer psychotropics, along with the deadly adverse events with these SSRI and SSNI meds only recently brought to the attention of others, other treatment options should probably be considered, but that is up to the discretion of the prescriber. And the perception of the benefits derived by these types of drugs may be flawed, as there has been no decrease in incidences of suicide or remission of depression since these drugs have been available, many have concluded. Furthermore, recent studies have suggested that the supplement, St. John’s Wart, has shown to be as effective as medicine for major depression. It is my hope that such a prescriber rules out possible other etiologies for their patients’ mental conditions before they conclude that such a patient is suffering from true mental illness requiring the medications mentioned earlier, such as asking their patients about life stressors and other medications these patients have taken in the past, for example. Because at times, a doctor can in fact do harm without intent.“I use to care, but now I take a pill for that.” --- Author unknownDan Abshear Author’s note: Addendum to this article based on the following link:

http://www.medicalnewstoday.com/articles/132005.php

There are greater than 60 symptoms associated with one who is or may be depressed, and there are different degrees of depression. The number of symptoms expressed by one who suffers from depression correlates with the severity of their depression.

The characteristics associated with depression are affective, cognitive, and somatic.

For example, affective symptoms are the core symptoms of a depressed mood, and the term that one has a flat affect is an indication that one may be suffering from depression. These symptoms may include sadness, dissatisfaction, crying episodes, irritability, as well as social withdrawal. It should be noted that many events could cause the expression of such symptoms besides depression in itself.

Cognitive symptoms associated with depression may include pessimism, a sense of failure as well as guilt, suicidal ideation, and dislike of self.

Somatic symptoms may include insomnia, fatigue, weight change, and loss of interests, such as sex or other activities engaged in historically with a depressed patient. It should be noted that stress can cause such symptoms as well, in my opinion,

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About Me

I'm an academic with a respectable amount of clinical experience and no drug industry funding. Given my lack of time, don't expect multiple daily updates. Certain things about clinical psychology, the drug industry, psychiatry, and academics drive me nuts, and you'll probably pick up on these pet peeves before long...